(2)
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA
Take-Home Message
Right thoracic curve common, can be progressive
Left thoracic curve needs MRI
Large curves can cause cardiopulmonary compromise
More common in females
Definition
Lateral curvature of the spine in the coronal plane of unknown cause
Etiology
Unknown
Family history of first-degree relatives important
Inner ear problem, proprioceptive cord problem, hormonal
Pathophysiology
Unknown
Lateral curvature causes rotational deformity and lends to progression
Radiographs
X-rays: Full-length standing films, first film AP and lateral as there can be sagittal plane imbalances as well, protect reproductive organs
Document Cobb angle and spinal balance, spinal rotation, apical vertebrae, stable vertebra, check clavicle angle (important for determining whether or not to include upper thoracic curve)
Use flexibility x-rays to further define curve behavior when deciding on operative treatment
Check pelvis for Risser grade (0–4)
MRI for left-sided curves and then look at whole spinal axis
Classification
King classification – older and less often used at meetings
Lenke classification – more complex but better able to use for treatment and especially for level selection, takes into account sagittal plane abnormalities in deciding structural nature of the curve
Treatment
Nonoperative
Observation for small curves and to document progression
Bracing for curves 25–45°
Type of brace determined by apex of curve, above T7 need Milwaukee-type brace, otherwise can use underarm orthosis
Brace wear should be full time, i.e., 23 h out of 24, but there are studies showing that less than full-time wear okay
Trying to halt progression, duration of brace wear at least 1 year and otherwise until skeletal maturity defined by multiple factors
Operative
Posterior fusion and fixation
Anterior fusion and fixation especially lumbar and thoracolumbar curves
Combined approaches for more severe or inflexible curves
Complications
Loss of correction
Adding on of the curve
Crankshaft phenomenon in pediatric patients
Pseudarthrosis
Infection
Neurologic injury
SMA syndrome can cause postop ileus
Special Situations
Infantile idiopathic scoliosis
Boys are more commonly affected
Left thoracic curve more common
Other congenital defects more common
Curves less than 30° can be observed
Look at study by Mehta, Cobb greater than 20°, RVA greater than 20°, and a phase 2 relationship define progression
Treatment casting, dual growing rods, or VEPTR
Bibliography
1.
Lenke LG. Lenke classification system of adolescent idiopathic scoliosis: treatment recommendations. Instr Course Lect. 2005;54:537–42.
2.
Mehta MH. The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br. 1972;54(2):230–43.
3.
Ward WT, Rihn JA, Solic J, Lee JY. A comparison of the lenke and king classification systems in the surgical treatment of idiopathic thoracic scoliosis. Spine (Phila Pa 1976). 2008;33(1):52–60. doi:10.1097/BRS.0b013e31815e392a.
2 Adult Spine Deformity
Samuel E. Smith3
(3)
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA
Take-Home Message
High complication rate treated operatively
Nonoperative treatment successful often
Severe pain and dysfunction attributable to positive sagittal balance
Difficult decision sometimes as to when or when not to fuse to the pelvis
Definition
Scoliosis especially of the lumbar spine caused by asymmetric development of lumbar spondylosis
May occur in preexisting adolescent idiopathic curve
Etiology
Degenerative cascade describe by Kirkaldy-Willis which is asymmetric
Pathophysiology
Degenerative cascade leads to disc and facet degeneration, and when this occurs, asymmetrically curve or deformity ensues
Frequently associated and exacerbated by osteoporosis and associate fractures
Can occur in preexisting AIS
When advanced can lead to flattening of lordosis beyond the ability of the pelvis to retrovert, normal lumbar lordosis roughly equal to pelvic incidence
Olisthesis, lateral, anterior, or retro often associated
Radiographs
X-rays: signs of spondylosis, Cobb angle, sagittal plane deformity, olisthesis
Must get full-length films to evaluate global balance
CT: defines bony anatomy and stenosis, more informative if done with myelographic contrast
MRI useful to evaluate for stenosis both centrally and in the foramen, radicular symptoms commonly in the concavity of the curve
Classification
Schwab classification: thoracic, TL/L, double curve, along with a description of the mismatch between the pelvic incidence and the lumbar lordosis as well as the SVA, i.e., the number of centimeters the C7 vertebra is in front of S1
Treatment
Nonoperative
Exercises, PT
Manipulative therapy
NSAIDs
Avoid opioids
Operative
Anterior release and reconstruction
Posterior release and reconstruction
Have to decide when and when not to fuse to the pelvis
Osteotomies sometimes employed, Ponte, PSO, VCR
Combined approaches
Complications
Infection
Loss of fixation, often bone density is poor
Pseudarthrosis especially L4/L5 and L5/S1
Smoking increases risk of failure of treatment both with respect to pain relief and fusion success
Neurologic injuryRelated posts:
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